4. FAMILY PLANNING KNOWLEDGE AND USE

Transcription

1 4. FAMILY PLANNING KNOWLEDGE AND USE Family planning activities have been integrated into maternal and child health services in Botswana since the beginning of the national programme in The policy of the Government affirms that these services be available to every family and it is the basic right of each family to determine the number of children and when to have them. Family planning services are available at all levels of health care including private doctors and pharmacies, although the majority of the services are provided by more than 440 public health facilities. Since 1984, family planning services have been available on a daily basis along with other curative and preventive services. The family planning programme offers a wide range of modern contraceptive methods: Oral Contraceptives (Pill), Intra-Uterine Device (IUD), Depo-Provera Injection, Condom, Diaphragm, Contraceptive Foam and Jelly, and Female and Male Sterilisation. Health facilities charge a nominal fee of 40 thebe, about 20 US cents, for out-patient consultations, including family planning services; condoms are provided without charge. Participation in the family planning programme is fostered by health education disseminated through home visits, kgotla, volunteer efforts, the media, schools, and talks at health facilities. The Family Health Division is in the process of developing alternative distribution outlets for contraceptives: a new programme offers condoms at the work place in selected private sector industries and plans are underway to launch a condom vending machine pilot project. This chapter looks at several aspects of the knowledge and use of family planning among Batswana women. It begins with an appraisal of the knowledge of family planning methods and sources of supply, and then presents findings on past and current use of contraception. The latter part of the chapter focuses on reasons for nonuse and discontinuation of contraception, intention to use in the future, attitudes of respondents toward family planning, and the acceptability of various sources of family planning messages. These topics are of practical use to policy and programme staff in several ways. The early sections concern the main pre-condition to adoption of contraception, knowledge of methods and sources of supply. Levels of contraceptive use provide the most obvious and widely accepted criteria of success for any family planning programme. Practical problems with particular methods, or more general doubts about family planning, that might prevent a woman from using contraception, are potential obstacles to further advances in the programme. Survey findings on these topics can guide administrators in the improvement and expansion of family planning services. Data on attitudes towards family planning and acceptability of media messages on family planning are useful in guiding the content of information and education campaigns and targeting groups 33

2 according to their need for information and the type of sources from which they are comfortable receiving information. 4.1 KNOWI.FJ')GE OF FAMILy PLANNING Knowledge of family planning methods and of places to obtain them are crucial elements in an individual or couple's decision whether to use family planning and which method to use. Presumably, improved knowledge of family planning methods will be followed by greater use. Data on knowledge of family planning methods were obtained by first asking respondents to name all the different ways that a woman or man could delay or avoid a pregnancy. If a respondent did not spontaneously name a particular method, the method was described by the interviewer and the respondent was asked if she recognized the method. Probing was used to collect data on 10 methods: pill, IUD, injection, diaphragm/foam/jelly (vaginal methods), condom, female sterilisation, male sterilisation, periodic abstinence (rhythm), withdrawal and prolonged abstinence. In addition, provision was made in the questionnaire to record any other methods, e.g., folk methods, spontaneously named by the respondent. For each modern method I named or recognized, the respondent was asked where she would go if she wanted to obtain that method. If the respondent knew of periodic abstinence, she was asked where she would go to obtain advice about the method. Finally, for all methods that the respondent knew, she was asked what problem, if any, she associated with the use of that method. The percentages of all women and women currently in union who know each method of family planning and a source for that method are shown in Table 4.1. Knowledge of modern methods of contraception is high in Botswana with 95 percent of all women knowing at least one modern method of family planning. Women not currently in union were as likely to know methods of family planning as women in union. Knowledge has increased steadily since the BFHS was conducted in In 1984, 75 percent of the women reported knowing at least one modern method of contraception, compared to 95 percent in Women are most likely to have heard of the pill, followed by the IUD, injection, and the condom. These were also the methods most often recognized in However, among all women, pill knowledge rose from 72 to 94 percent, IUD knowledge from 66 to 89 percent, knowledge of injection from 62 to 88 percent, and condom knowledge from 48 to 87 percent. Male sterilisation, diaphragm, foam, and jelly, and female sterilisation are the least known of the modern methods. The low level of knowledge of vaginal methods can be attributed to the lack 1 Modern methods of family planning include the pill, IUD, injection, diaphragm/foam/jelly, condom, and female and male sterilisation. 2 The 1984 BFFIS differed somewhat from the BFHS-II in the manner in which information on contraceptive knowledge was collected. In both surveys, women were first asked to name all the family planning methods that they knew. Interviewers then probed to find out if women recx)gnized methods they had not mentioned spontaneously. In the 1984 BFHS, the interviewers used only the name of the method when they probed; in the BFHS-II both the name and a brief description were used. Some of the difference in knowledge between the two surveys may be related to differences in the probing techniques. 34

3 Table 4.1 Percentage of At[ Women end Wo~nen Currently In Union ~/ho Know a FamiLy PLanning Method and ~ no Know a Source (For Information or Services), by Specific Method, BFHS-II 1988 Know Method Know Source Womn Wu~en All Currently ALL CurrentLy Method Women in Union Wo nen in Union Any Method 95, Any Modern Method 95, Pitt 94, IUD 89, Injection 87, Diaphragm/Foam/JeLLy 50, Condom 87, FemaLe $terilisation 57, Mate Steritisation Any Traditional Method 41, Periodic Abstinence 23, Withdrawal Other 3,1 3.9 Abstinence 27, Number Question not asked. of attention paid to these methods by health workers. While health workers are instructed to provide information on all methods offered by the programme, in practice emphasis is on temporary methods which are perceived to be both effective and easy to use, such as the pill, IUD, and injection. Although knowledge of vaginal methods and female and male sterilisation continues to lag behind that of other modern methods, knowledge of these methods also rose significantly between 1984 and Traditional methods were named less frequently in the 1988 survey than in Reported knowledge about traditional methods is particularly sensitive to the degree of probing and it is possible that differences in questionnaire design account for the lower reporting of these methods in the BFHS-II. However, it is logical that there would be a reduction in the dissemination of information about these methods as modern methods become more accessible. Lack of knowledge of sources for methods is not an obstacle to use in Botswana. Columns two and four of Table 4.1 show that virtually all women who have heard of a method were able to name a source for that method. This is not surprising, as the government health network is widely recognized as a source for all health care including family planning. The percentages of all women knowing a modern method of family planning and a source for that method by selected background characteristics are presented in Table 4.2. There is little variation in knowledge of methods and sources among sub-groups of Batswana women. There are no differences in the level of knowledge by whether the respondent is currently or was formerly 35

4 in union, or has never been in union. Except for the oldest women, more than 90 percent of women regardless of age know a modern method and a source. The highest level of knowledge is found in the age group. Respondents residing in rural areas show only a slightly lower level of knowledge than urban dwellers. Looking at the data on knowledge by level of education, respondents with no education are less knowledgeable about methods or sources in comparison with the remainder of women who have attended school. Table 4.2 Percentage of All Women Who Know at Least One Modern Method of Family Planning and Who Know a Source for a Modern Methnd, by Selected Background Characteristics, BFHS-II 1988 Know Number Background Modern Know of Characteristic Method Source women Union Status Never in Union Currently in Union PrevicaJsLy in Union 94.4 g Age B Residence Urban Rural Education No Education Incoraptete Primary Co~plete Primary Secondary or Higher Total ~ 4.2 KNOWI.FDGE OF SOURCES FOR FAMILY PLANNING ME-IHODS Table 4.3 shows that most women who know a method named the government clinic as the source of supply, although government health posts are the most common type of public health facility. It appears that many respondents did not differentiate between a health post and a clinic and simply referred to their local health facility as a clinic. Private doctors and clinics and pharmacies play a minor role in supplying methods in Botswana. The popularity of government facilities is undoubtably due to the fact that they are easily accessible and that family planning services are provided free or at a very low cost. 36

5 Table 4.3 Percent Distril~Jtion of Women I/no Kno~ a Famity Planning Method by Supply Source They Would Use if They Wanted the Method, According to Specific Nethod, BFHS-II 1988 Family Planninq Method Known Diaphragm/ Female Note Supply Source Foam/ Steriti- Sterfti- Periodic Named Pitt IUD Injection Jelly Condom sation sation Abstinence* Governn~nt Health Post , Government Clinic , Government Hospitst/ Health Centre Private Doctor/Clinic , Pharmacy Other , None , Oon't knom Nissing , Total Nunt~er of Wo~en * Refers to source for information about the method. Slightly over 20 percent of the women who knew about female or male stcrilisation reported the government clinic as a potential source of the operation. However, sterilisations are carried out only in health centres and hospitals. These women may be misinformed about obtaining female or male sterilisation at a government clinic or, again, they may not be clearly differentiating between various types of health facilities. 43 ACCEPTABILITY'OF ME-mHODS In order to identify potential obstacles to the wider use of family planning methods, women in the BFHS-II who reported knowing a method of contraception were asked what was the main problem, if any, they perceived in using the method. Table 4.4 shows the distribution of women who have heard of a method, by the main problem they perceive in using the method. As can be seen in Table 4.4, only a minority of women reported knowing of problems with methods. The proportion reporting "no problem" with the method ranges from 16 percent for injection to 69 percent for prolonged abstinence. Additionally, many women answered "don't know" when asked about problems with specific methods: 18 percent for periodic abstinence to 63 percent for the diaphragm/foam/jelly. Nevertheless, significant minorities of women reported concerns about specific methods. One in three women who know the pill, IUD, or injection reported that health concerns were the major problem with the method. One-quarter of the women who know about female or male sterilisation reported the irreversibility of the method as a problem. One in seven women who know about periodic abstinence or withdrawal reported that they were ineffective. More women than one would expect, 9 percent, considered the IUD to be ineffective. Another unexpected result is that 9 percent of women who know about injection reported the 37

6 main problem to be that the method was permanent. This suggests that some women are misinformed about the efficacy and reversibility of these contraceptive methods. Table 4.4 Percent Distribution of Women Who Know a Family Planning Method by Main Problem Perceived in Using the Method, According to Specific Method, 8FHS-II 1988 FamiLy Planning Method Known Oiaphragr~/ Fe~te ~ate Periodic Main ProbLem Foam/ Sterit- Sterit- Absti- With- AbSti- Perceived Pitt IUD Injection Jetty condom isation isation hence drawat nence No prob't em /* Not effective , Partner disapproves Health concerns ,2 14, Access/avai tabi [ i ty O.O Costs too much Inconvenient to use Method permanent Other Don't know Missing Total Number of Women The fact that the respondents did not mention cost, access, or availability as a problem reinforces the impression that the majority of the population is aware of the widespread availability of family planning services in the country. It is also interesting to note that few women reported partner's disapproval to be a problem in using any of the methods. 4.4 EVER USE OF FAMILY PLANNING METHODS More than half of Batswana women have used a modern method of family planning at some time. Table 4.5 shows that the method used by most women, 46 percent, was the pill. The IUD has been used by 13 percent of women, and contraceptive injection by 10 percent. The least used modern methods are vaginal methods and male sterilisation. Ever use of traditional methods is much lower than that of modern methods. The pill has been widely used among women in all age groups with the highest percentage of ever-use among women aged IUD use has been concentrated among women currently between the ages of 25 and 34, while injection has been used mostly by women over age 35. This age pattern of method use reflects the general practice of the family planning programme to recommend the pill to childless women, the IUD to younger women with children, and injection to women over 35. The number of living children at the time of the first use of family planning is an indicator of whether contraception is being adopted to delay or limit births. Table 4.6 presents the percent 38

7 Table 4.5 Percentage of ALL Women and Wo~en in Union Who Have Ever Used a Family Planning Method by Specific Method and Age, BFHS-I! 1988 Family PLanning Method Ever Used Any Any Tra- Diaphragm/ Female Mate Number Any Modern ditionat Foam Steriti- steriti- Periodic With- Absti- of Age Method Method Method Pill IUD injection Jetty Condom sation sation Abstinence drawa[ Other nence Women ALL Women , , , Total Wo~en In Union , O.O , Total

8 distribution of all women by the number of living children at the time they first used family planning. In interpreting the data in Table 4.6, it is important to keep in mind that the family planning programme in Botswana is only 15 years old, and as such, older women had little access to contraception when they were bearing their first children. Table 4.6 Current Age Percent Distribution of All ~o~nen by Number of Living children at Time of First Use of Contraception, According to Current Age, BFHS Number of Livin R Children Number Never of Used None Nissing Total Women , , Total The use of contraception for delaying a first birth and spacing subsequent births has clearly been adopted by younger women. Twenty percent of women age used a contraceptive method before their first birth. Thirty percent of women age adopted contraception to delay their second birth. The use of family planning for spacing purposes is consistent with the policy of the family planning programme, which is to provide family planning services "to benefit the health and welfare of individuals and of the families". In practice, this means an emphasis on family planning for spacing rather than limiting purposes. A basic knowledge of the reproductive cycle and the fertile period are important for the successful practice of periodic abstinence. In the BFHS-II, women were asked when during the menstrual cycle they thought a woman has the greatest chance of becoming pregnant. Table 4.7 presents the distribution of all women, and those women who have ever used periodic abstinence, by the time during the ovulatory cycle when they think a woman is most likely to get pregnant. Although the interviewers provided an additional probe, many respondents had great difficulty in answering this question. The majority of the women responded "don't know". It is difficult to ascertain whether they really did not know or they could not understand the question. Ever-users of periodic abstinence appear to have at least understood the question, suggesting that they had some knowledge of the existence and importance of the fertile period. Three-quarters of ever-users of periodic abstinence provided an answer to the question, although only 8 percent gave the correct answer, "in the middle of the cycle". This lack of knowledge about the ovulatory cycle is an issue which needs to be addressed, not only for users of periodic abstinence--for whom the correct knowledge is critical to successful use of the method--but also for all women to educate them about their physiology. 40

9 Table 4.7 Percent Distribution of All Women and Women Who Have Ever Used Periodic Abstinence by Knowledge of the Fertile Period During the Ovulatory Cycle, BFHS-%! 1988 Periodic All Al~tinence Fertile Period Women Users During her period Just after her period has ended Middle of the cycle Just before her period begins At any time Other Don't know Missing Total Number of Women CURRENT USE OF FAMILY PLANNING M~-IHODS Table 4.8 shows that 33 percent of women in union and 30 percent of all women were currently using contraception at the time of the BFHS-II. Virtually all use is modern methods. Nearly half of current users rely on the pill. Of the rest, most are using the IUD, injection, and female sterilisation (the latter method being concentrated among women in union). Both prevalence and method mix vary with age. Younger and older women are less likely to use family planning than women in the mid-childbearing years. The pill and IUD are the principal methods among women under 39, whereas injection and female sterilisation are more commonly used by women age 40 and over. As seen in Table 4.9, the median age at sterilisation is 34 and, on average, a woman has 5.4 children at the time of the sterilisation procedure. The data in Tables 4.8 and 4.9 show that method use by age and parity generally follows the Botswana Family Planning Policy Guidelines, which provide the following recommendations: - All women who are under 35 years of age and for whom there are no contraindications are eligible to use the combined oral contraceptives as a method of contraception. - ALl women with at least one living child and for whom there are no contraindications may use an IUD. - Couples and individuals who feel they have achieved a desired family size and those who cannot use other methods may use Depo-Provera. Lactating mothers may also use Depo-Provera as a contraceptive method. - Sterilisation methods of contraception should be provided to clients who feel they have achieved a desired family size. 41

10 Table 4.8 Percent Distribution of ALL women and Women in Union by Current Use of Specific Family PLanning Methods, According to Age, BFHS'II 1988 Family Ptannin 9 Method Used Any Diaphragm/ Female Male Periodic Prolongod Nunioer Any Modern %njec- Foam/ Sterili- $terili- Absti- With- Absti- Not of Age Method Method Pill IUD tion Jetty Condom sation sation nence drawal Other nence Using Total Women ALL Women DO I ~ Total I 0.I Wo~en In Union Total

11 Table 4.9 Percent Distribution of Steritised Women by Age and Median Age at the Time of the Sterilisation, and Percent Distribution of Steritised Women by Number of Children and Mean Number of children at the Time of Sterilisation, BFHS-I! 1968 Afle at the Time of the Steritisation < Total Number Median Sterilised Women Number of Children at the Time of the Steritisation Tota[ Number Mean Steritised Women The principal exception to compliance with the guidelines is that a significant number of women aged 35-39, and a smaller number over age 40 are currently using the pill. There are elevated health risks involved in using the pill for women over 35. The number of older women who use ~'the pill as their contraceptive method, contrary to programme guidelines, is a concern that should be addressed by programme managers. Table 4.10 Percent Distribution of All Women and Women in Union by the Family Planning Method Currently Used, BFHS 1984 and BFHS-i! 1988 All Women Women in Union Method BFHS BFHS-[! BFHS BFKS-ii Any Method Any Modern Method Pill IUD Injection Diaphragm/Foam/Jet ty Condom Female Steri I isation Mate Steritisation Any Traditional Method Not Currently Using Total Number of Wa~en

12 Figure 4.1 Current Use of Specific Methods of Family Planning, Women 15-49, 1984 and 1988 Injection 5~ Pill 36% Pill 60% IUD 17% Trad. Meth. 3% Other* 1C Trad. Meth. 32% Injection 11 IUD 15% ~ther* 12% BFHS 1984 Prevalence - 24% BFHS-II 1988 Prevalence - 30% * Includes condom, vaginal methods, female end male sterlllsatlon Table 4.10 and Figure 4.1 compare the current use of family planning reported in the 1984 BFHS with the results from the 1988 BFHS-II. Overall, the increase in contraceptive prevalence among all women is just over six percentage points. However, use of modern methods has almost doubled, increasing from 16 to 29 percent. As seen in Figure 4.1, the major increascs are in the use of the pill, injection, and female sterilisation. IUD use rose only slightly among women in union. There appears to be no change in condom use, despite increased efforts to promote use of this method in the past few years. The low reporting of condom use may be associated with the difficulty in getting women to report use of a male method. Only one percent of the women in the BFHS-II reported using traditional methods, compared with 9 percent in Current contraceptive prevalence for all women by selected background characteristics is shown in Table Differences in contraceptive prevalence by marital status are small, though use is slightly higher among currently married women. There are significant differences in overall contraceptive use between urban and rural dwellers. Thirty-nine percent of urban women use contraception, compared with 26 percent of rural women. The majority of users in both urban and rural areas rely on the pill. Urban women are more likely to use the IUD, while injection is more common among rural women. 44

13 TabLe 4.11 Percent Distribution of ALl gon~n by Current Use of Specific Family Planning Methods, According to Selected Background Characteristics, BFHS-ii 1988 Family Plannin 9 Hethod Used Any Female Mate Any Tradi- Number Background Any Modern Sterili- Sterili- tiona[ Not of Characteristic Method Method Pill ILID injection Conclm sation sation Method Using Total Women Union Status Never In Union Currently In Union Previously in Union Residence Urban Rural (.h Education No Education Incomplete Primary Colnp[ ete primary Secondary or Higher Number of Living Children None I , or more Religion Spiritual/African Protestant Catholic Other No Net igion Total ;'

14 The use of family planning is related to a woman's level of education. Prevalence increases from 18 percent among women with no education to over 40 percent among women who have some secondary or higher education. The variation in method mix according to education is related to the interaction between age and educational level. Older women are concentrated among the least educated and younger women among the most educated. Hence, women with no education, who are older, are more likely to be using injection, while women with primary or higher education, who are younger, are more likely to be using the pill or IUD. The reliance on contraception for spacing can be clearly seen in the variation in the use of specific methods by number of living children shown in Figure 4.2. Fourteen percent of childless women are using contraception to delay a first birth. These women rely mainly on the pill. Prevalence is twice as high (31 percent) for women with one child. Again, the principal method is the pill, though about one-tenth of users have adopted the IUD. The use of family planning peaks among women with two or three children. Among these users, the proportion relying on the pill declines slightly, IUD use increases, and injection is added to the method mix. Finally, among women with four or more children, pill and IUD use decline, the use of injection increases, and one out of six users has chosen female sterilisation * Figure 4.2 Current Use of Family Planning by Number of Living Children No. of Living Children Percent R Pill ~-~ IUO J Female Ster. ~ Other Injection i BFHS-II

15 With regard to religion, Protestant and Catholic women are more likely to use contraception than women belonging to the Spiritual/African churches or who report no religion. While the lower use among women of the Spiritual/African Church is more likely due to associated socioeconomic characteristics--such as lower education (see Table 1.2)--rather than to religion per 5e, the findings suggest that the churches are a potential way of reaching these women. Table 4.12 Percentage of All Wo~en Currently Using a Nndern Nethod of Family Planning, According to Selected Background Characteristics, gfhs 1984 and BFHS-i! 1988 Currently Using Background Rodern Rethnd Characteristic BFHS BFHS-H Union Status Never In Union Currently In Union Previously In Union ,9 Age Residence Urban ,2 Rural Education No Education Incomplete Primary complete Primary Secondary or Higher Number of Living Children None I or more 17~ Religion Spiritual/African Protestant Catholic Other No Religion Tote[

16 Table 4.12 shows the percentage of all women and women currently in union using a modern method of family planning according to selected background characteristics, for 1984 and Contraceptive prevalence among women never in union and women previously in union has risen sharply since Caution should be used in comparing the data for women never in union, as the definition used in the 1984 BFHS is much more likely to restrict this category to women who are not sexually active, while the definition used in the BFHS-II includes many sexually active women. Prevalence among women never in union increased from 3 to 27 percent, while prevalence among women previously in union increased from 10 to 29 percent. The impact of introducing family planning services on a daily basis most likely had a large impact on women not currently in union, as this change removed the potential for embarrassment if seen going to the clinic on the days when it was known that only family planning services were being offered. Figure 4.3 Knowledge and Use of Modern Methods of Family Planning, Women 15-49, 1984 and 1988 Percent loo o_ / BFHS 1984 BFH Know method ~ Ever used method ~11 Currently using Contraceptive prevalence has increased dramatically among women between the ages of 20 and 45, with more modest gains among the youngest and oldest women. The use of family planning increased significantly both among urban and rural women and among all women for all levels of education and religious backgrounds. One of the largest relative gains was made among women with no children, for whom use of modern family planning methods trebled since

17 Figure 4.3 summarizes the changes in knowledge and use of modern methods of family planning between 1984 and In 1984, three-quarters of Batswana women knew at least one modern method of family planning, but only one-third had ever used a modern method and half of those women, 16 percent of all women, were currently using a modern method. By 1988, knowledge of modern methods was virtually universal. Slightly more than half of all women had used at least one modern method and almost 30 percent were using a modern method of family planning at the time of the survey. 4.6 CURRENT SOURCE OF SUPPLY OF FAMILY PLANNING METHODS Family planning services are available on a daily basis at all levels of the government health care delivery system--hospitals, health centres, clinics, health posts, and mobile stops. Most family services are offered by nurses who have been trained in MCH/FP and who are responsible for prescribing pills, inserting IUDs and performing post-insertion check-ups, giving injections, monitoring clients for any contra-indications or side effects and advising women who experience side effects. The family welfare educator, who usually is the sole staff member of the health post, distributes condoms and foam and resupplies pills to users who have experienced no problems. The family welfare educator also can provide the first cycle of pills to new acceptors; however, new acceptors must be examined by a nurse before being resupplied. Outside of the public health care delivery system, contraceptive methods also can be obtained from private doctors and pharmacies. There are no private non-profit organizations providing family planning services in Botswana. Table 4.13 Percent Distribution of Current Users by Most Recent Source of Supply or information, According to Specific Method, BFHS It 1988 Supply Methods Clinic Methods Female Source of Injec- SteriLi- All Supply Pitt Condom tion Total IUD sation Total Hethods Government Health Post Government Clinic Government Hospital or Health Centre Private Doctor Z.O or Clinic Pharmacy Other Don~t know Missing Total Number of Current * ** 1264 Users * l~l~es one diaphra~ user. ** Includes four women who reported that their current method was mate steritisation. 49

18 As shown in Table 4.13 and Figure 4.4, government clinics and hospitals are the major source of contraceptives. The major source of supply methods, i.e., pill, condom, and injection are government clinics. Health posts are most likely under-reported because respondents may not differentiate between a clinic and a health post. The reported source of clinical methods is split between government clinics and hospitals. Private providers, doctors and pharmacies, are the source of only 4 percent of users of supply methods, principally condom users, and 8 percent of users of clinical methods. Fourteen percent of condom users did not know the source, probably because they were obtained by their partners. Current users of a contraception method were asked whether there was anything they particularly disliked about the services received at their current source of supply. Ninety-eight percent of the users said that they did not encounter any problems with the services. Figure 4.4 Source of Family Planning Supply Current Users of Modern Methods Other- 1% Private Doctor 4% Pharmacy 1% Government 94% Includes categories Don't Know and Missing BFHS-I REASONS FOR DISCONTINUATION AND NONUSE OF FAMILY PLANNING Of primary importance to programme administrators are the reasons why family planning users stop using their adopted method. Table 4.14 considers the main reasons for discontinuing the last method, among women who have discontinued use of a method during the five years preceding the survey. The table indicates that the most common reason for discontinuing a method 50

19 was health concerns, mainly associated with injection (63 percent), the IUD (41 percent), and the pill (32 percent). The second most cited reason for discontinuing a method was the desire to become pregnant; 36 percent of the women discontinued using the pill and the IUD and 32 percent discontinued using a traditional method in order to become pregnant. The most commonly cited reason for discontinuing traditional methods was method failure. A high level of method failure was also reported for the pill and IUD; some of the these IUD failures might be rejection of the IUD from the uterus. Tabte 4.1& Percent bistrib~jtion of ~omen ~ho Rave Discontinued a Contraceptive Method in the Last Five Years by Main Reason for Last Discontinuation, According to Specific Method, BFHS-II 1988 Method Discontinued Any Reason for Injec- lraditionsl All Discontinuation Pitt IUD tion Condccn Method Methods To become pregnant Method faitod Partner disapproves Health concerns 32, , ,4 Access/availability Inconvenient to Use Infrequent sex Prefer Permanent Method Fatalistic O.O 0.1 Other DonJt know Missing Total Number " * Includes 6 women who discontinued the diaphragm and 17 women whose last method was missing. Condom users reported a variety of reasons for discontinuing including health concerns-- as condom use is also associated with the prevention of sexually transmitted disease, some women may disapprove of condoms for fear of the implication that they have such a disease. Other reasons for discontinuing condom use are that the partner disapproves, the method is inconvenient, and preference for a more permanent method. By the latter, it is likely meant preference for a method that is not associated with coitus. The group of women who discontinued contraceptive use due to health concerns most likely encompasses both women who experienced health related problems with their family planning method or were advised against using the method, and women who discontinued due to rumors or myths which people still hold about modern family planning methods. The high levels of failure reported for the pill and the IUD suggest that women may use the method improperly. Finally, there appears to be dissatisfaction with the condom for a number of reasons. In order to sustain 51

20 continued use, the programme should intensify efforts to inform users about the methods they adopt and follow-up to ensure that methods are used' properly. Table 4.15 gives the distribution of non-pregnant women who are sexually active and not using any contraceptive method by whether they would be happy or unhappy if they became pregnant in the next few weeks. The table shows that a significant percentage of women (48 percent) said they would be unhappy, an indication that many women would prefer to wait before the next pregnancy. Forty-four percent of the respondents expressed a desire to become pregnant soon. Few women (8 percent) said it wouldn't matter. The majority of women with three or more children said they would be unhappy if they became pregnant in the next month. Table 4.15 Percent Distribution of Non-Pregnant women Who Are Sexually Active and Who Are Not Using Any Contraceptive Method by Attitude Toward Becoming Pregnant in the Next Few Weeks, According to Number of Living Children, BFH B~B Would Number Number of Not of Living Children Nappy Unhappy Matter Missing Total Women Hone , , , Total The women that reported that they would be unhappy if they became pregnant were then asked why they were not using a method of contraception. Table 4.16 gives the distribution of non-pregnant, nonusers by age and main reason for nonuse. Women less than age 20 cited a variety of reasons for not using family planning even when they would be unhappy if they became pregnant. Twenty percent of the respondents said they were opposed to family planning, and another 10 percent said their partners or others disapprove. Seven percent said they did not know about family planning, while 15 percent feel the costs are too much--another indicator of lack of knowledge since methods are available at a nominal cost or free. An additional 7 percent cited health concerns about using family planning and 4 percent thought family planning was inconvenient. Twenty-five percent of young women could not provide a reason for nonuse of a method. Responses to a question on why the respondent did not use a method of family planning the first time she had sexual intercourse were also tabulated for women under 20. Over two-thirds of teenagers cited lack of knowledge of family planning as the reason for not using contraception at that time. Eleven percent said they were opposed to family planning and another 5 percent said their partner or others disapproved. Difficulty in getting methods, or that family planning was 52

21 Table 4.16 Percent Oistribution of Non-Pregnant ~omen kho Are Sexuaity Active and ~ho Are Not Using Any contraceptive Nethed and ~/ho Would be Unhappy if They Became Pregnant by Nain Reason for Nonuse, According to Age, BFHS-I! 1988 Reeson for A~e Nonuse < Totat Lack of knowledge Opposed to family planning Partner disapproves Others disapprove Infrequent sex Post-partum/breastfeeding Nenopeusat/subfecund Health concerns Access/availability Costs too much Fatalistic Religion Inconvenient Other Don't knou Nissing Total Number of Woc~n inconvenient to use, were each mentioned by 3 percent of teenagers. Eight percent said they did not know why they did not use a method at that time. A significant percentage of the women over age 20 cited inconvenience and infrequent sex as the main reason for nonuse. Opposition to family planning by the respondent or her partner were also important reasons. While only a small percentage said they do not know about family planning, a larger proportion perceived the cost to be excessive. These data suggest a number of obstacles that Batswana women perceive to be barriers to using family planning. The results imply a need for an effective information, education, and communication programme that would build acceptance of family planning, reassure women about the benefits as well as risks of family planning, portray family planning as something that is easy to use, and spread the word that family planning methods are widely available for only a nominal cost. 4.8 INTENTIONS TO USE FAMH.Y PLANNING IN THE FUTURE The data in Table 4.17 give an indication of the intent of nonusers to use a contraceptive method in the near future. More than 50 percent of the respondents indicated that they would use contraception in the future, and most said they would use in the next 12 months. Forty percent of the women do not intend to use family planning in the future and the remaining women were undecided. 53

22 Table 4.17 Percent Distribution of women Who Have Had Sexual Intercourse Who Are Not Currently Using Any Contraceptive Method, by Intention to Use in the Future, According to Number of Living Children, BFNS-II 1988 Intention to Number of Living Children Use in the Future None Total Intend to Use in Next 12 Months Intend to Use Later Intend to Use, Unsure about When Unsure about Whether to Use Does Not intend to Use Missing I Total Number Table 4.18 Percent Distribution of Woenen Who Have Had Sexual Intercourse Who Are Not Using a Contraceptive Method but Who Intend to Use in the Future, by Preferred Method, According to ~hether They ]ntend to Use in the Next 12 Months or Later, BFHS-II 1988 Intend to Preferred Use in Next Intend to Method 12 Months Use Later Total Pitt IUD Injection Oiaphrag~FoanVdetty Condom Female Steritisation Periodic Abstinence Other Abstinence Oon't know Total Number of Women 129S Women who were not using contraception but who intend to use a method were asked which method they preferred. Table 4.18 presents the distribution of women according to their preferred method and whether they intend to use in the next 12 months or not. The majority of the respondents plan to use the pill, with much smaller proportions stating a preference for the IUD and injection. 54

23 4.9 ACCEPTABILITY OF ME~DIA MESSAGES ON FAMII.y PLANNING Information about family planning is disseminated through various channels: home visits, kgotla, schools, community meetings, work places, individual counselling, and talks at health facilities. In the BFHS-II, respondents were asked whether it was acceptable to them for family planning to be advertised through the radio, kgotla or school. Table 4.19 Percentage of All Women Who Believe Thet it is Aceeptebte to Have Messages About Family Ptenning on the Radio, et Kgotla, and at School, by Age, BFHS-II 1988 Source of AQe FP Message Tota[ Radio Kgotla School Table 4.19 shows the percentage of all women who believe it is acceptable to have family planning messages on the radio, at kgotla, and at school. The school is the most widely accepted source for family planning information with 85 percent of the respondents finding this to be an acceptable source. Fewer respondents chose the kgotla as a forum for disseminating family planning messages. The radio was less acceptable than either the school and kgotla with only 55 percent approving of the radio as a source of family planning information. The acceptance of media messages on family planning at school steadily declines with increases in age; almost 90 percent of teenagers approve of family planning messages in the school, but only about three-quarters of women over 40 approve. The kgotla is most popular among those aged 20-34, but less popular among the youngest and oldest women. Acceptance of radio has the opposite age pattern; it is most acceptable among the youngest and oldest women, and less acceptable to those between the ages of 25 and APPROVAL OF FAMILY PLANNING BY RESPONDEN'/~ AND PARTNERS Information was collected in the BFHS-II regarding whether women approve of the use of contraceptive methods and whether women currently in a union think that their partners approve of family planning. As shown in Table 4.20, 92 percent of women who know at least one method of contraception approve of family planning. The proportion of women knowing a method who approve of family planning is the same as in the 1984 BFHS. Table 4.21 presents the respondents' opinion about their partner's attitude toward the use of family planning, for all women in union. Fifty-seven percent said their partner approved, one-third thought he disapproved and 9 percent were unsure. Women in union who knew a contraceptive method were asked the number of times they discussed family planning with their partner. Inter-partner communication is an important step 55